Primary Hip Arthroscopy Research Articles

Long-Term Outcomes of Primary Hip Arthroscopy With Labral Repair for Femoroacetabular Impingement: Results at Minimum 9-Year Follow-up.

Hip arthroscopy continues to advance and become increasingly commonly performed. With the evolution of techniques and instrumentation, labral repair rather than debridement has emerged as the treatment of choice for labral pathology. There remains a lack of data on long-term outcomes after labral repair. To (1) evaluate long-term patient-reported outcomes of primary hip arthroscopy with labral repair for femoroacetabular impingement, (2) report achievement rates of Patient Acceptable Symptom State (PASS) and minimal clinically important difference (MCID), and (3) investigate rates of reoperation and progression to total hip arthroplasty (THA). Case series; Level of evidence, 4. Prospectively collected data were reviewed for patients who underwent primary hip arthroscopy with labral repair between 2010 and 2013. Patients' medical records were reviewed for demographic characteristics, intraoperative findings, reoperation, and progression to THA. Patients were assessed pre- and postoperatively using the following scales: visual analog scale (VAS) for pain; Tegner activity scale; modified Harris Hip Score (mHHS); 12-item International Hip Outcome Tool (iHOT-12); Hip Outcome Score-Activities of Daily Living (HOS-ADL); HOS-Sport-Specific Subscale (HOS-SSS); and Non-Arthritic Hip Score. Patients were also surveyed for satisfaction, subjective improvement, and level of function. A total of 32 patients (n = 24 women; n = 8 men) with a mean age of 27.7 years (range, 13.6-51 years) were evaluated for a mean of 9.4 years (range, 9-12.1 years). Patients achieved significant mean improvements in VAS pain at rest of 2 points, VAS pain with use of 1.9, mHHS of 19.9 points, iHOT-12 of 33.5 points, HOS-ADL of 17.4 points, and HOS-SSS of 29.5 points (P≤ .015 for all). Eleven patients (34.4%) underwent reoperation and 4 (12.5%) progressed to THA during the study period. At the final follow-up, the MCID achievement rate was ≥68%, the PASS achievement rates ranged from 39% to 65%, and the mean patient satisfaction was 8.1 on a 1 to 10 scale, with 10 denoting most satisfied. Patients demonstrated significant postoperative improvements in pain, mHHS, iHOT-12, HOS-ADL, and HOS-SSS scores at 9 years postoperatively. The all-cause reoperation rate was 34.4%, and 12.5% of patients progressed to THA.

Satisfactory Clinical Outcomes and Continuance of Sports After Hip Arthroscopic Labral Repair in Young Competitive Athletes at Minimum 8.5-Year Follow-Up

PurposeTo (1) evaluate long-term patient-reported outcomes and achievement rates of patient acceptable symptomatic state (PASS) in young athletes undergoing hip arthroscopy, and (2) report long-term sports continuance and reoperation. MethodsInclusion criteria consisted of age <24 years at surgery, femoroacetabular impingement undergoing primary hip arthroscopy with labral repair, and participation in sport with intent to return to sport after surgery. The enrollment period was from April 2009 to June 2014. Modified Harris Hip Scores (mHHS), Hip Outcome Score (HOS), HOS Activities of Daily Living (HOS-ADL), and HOS Sport (HOS-Sport) were collected preoperatively, 2 years’ postoperatively, and final follow-up. Patients were evaluated for PASS achievement, reoperation, and sports participation. ResultsForty-two hips in 37 patients (11 male, 26 female, age: 17.7 ± 2.1 years, range 13.6-23.0, body mass index 22.8 ± 2.9, range 17.6-33.7) met inclusion criteria and were followed for 10.0 ± 1.3 years (range 8.5-13.0) postoperatively. Mean mHHS, HOS-ADL and HOS-Sports outcome scores at minimum 8.5 years were 82.2 ± 12.9, 89.6 ± 10.9, and 81.8 ± 16.4, respectively, with significant (P < .001) postoperative improvements. Thirty survey respondents (83%) met PASS for mHHS, 27 (75%) for HOS-ADL, and 24 (67%) for HOS-Sports. At minimum 8.5-year follow-up, only 9 of 37 (24%) cited their hip as the reason for stopping sport. Of the remaining patients, 17 of 28 (61%), continued playing their initial sport. There was no difference in patient-reported outcomes between patients who endorsed sports continuance and patients who did not report sports continuance and did not cite their hip as a reason (P ≥ .229). At final follow-up, 4 hips (10%) had undergone subsequent surgical intervention at a mean of 4.8 ± 3.3 years (range 1.0-8.4) postoperatively. ConclusionsDurable mid-term outcomes and satisfactory PASS achievement rates are observed in young amateur athletes undergoing primary hip arthroscopy. At minimum 8.5-year follow up, approximately 1 in 4 patients discontinue their sports due to hip related reasons. Level of EvidenceLevel IV, case-series.

Borderline Hip Dysplasia Is Not Associated With Significant Differences in Hip Survivorship or Patient-Reported Outcomes Following Primary Hip Arthroscopy for Femoroacetabular Impingement Syndrome: A Propensity-Matched Cohort Study

To compare hip survivorship and patient-reported outcomes after primary hip arthroscopy for femoroacetabular impingement syndrome (FAIS) in patients with versus without comorbid borderline hip dysplasia (BHD) at 2-year follow-up. A retrospective matched-cohort study was conducted involving patients who underwent primary hip arthroscopy for FAIS with a single surgeon from 2010 to 2019. BHD was defined as lateral center edge angle (LCEA) of 20 to 25°. Subjects with BHD were matched 1:2 to controls without BHD on age, sex, body mass index, and preoperative modified Harris Hip Score (mHHS). Alpha angle, LCEA, Tönnis angle, and acetabular retroversion signs were measured on preoperative and/or postoperative hip radiographs. Patient-reported outcomes were assessed using the mHHS and the Non-Arthritic Hip Score. Hip survivorship, outcome scores, and achievement of the minimum clinically important difference were compared between groups using the Mann-Whitney U test or Fisher exact test, as appropriate. P values <.05 were considered significant. Thirty-one BHD subjects (mean age 36.8 years, 71.0% female) and 62controls (mean age 38.0 years, 71.0% female) were included. There were no significant intergroup differences in demographics or preoperative radiographic measurements besides LCEA and Tönnis angle (all P > .05). Intraoperatively, subjects with BHD were found to have significantly shorter labral tears (mean 2.6 vs 2.8 clock-face hours, P= .048), but there were no significant intergroup differences in acetabular or femoral cartilage status (all P > .05). Postoperatively, there were no significant intergroup differences in rates of revision arthroscopy (BHD 6.5% vs control 11.3%) or conversion to total hip arthroplasty (BHD 9.7% vs control 1.6%), in 2-year improvement of the mHHS and Non-Arthritic Hip Score, or in minimum clinically important difference achievement rates (all P > .05). BHD is notassociated with a significant difference in hip survivorship or patient-reported outcomes following primary hip arthroscopy for FAIS. Level III, retrospective comparative study.

Effect of cam resection depth on clinical outcomes after primary hip arthroscopy.

The amount of resection or the starting point of the resection on the femoral head for cam lesions in femoroacetabular impingement (FAI) is controversial. The purpose of this study was to study the effect of postoperative resection depth, and resection arc ratio of cam lesion on the frequency of achieving substantial clinical benefit (SCB), patient acceptable state (PASS) in modified Harris Hip Score (mHHS) and Hip Outcome Score Activity of Daily Living (HOSADL), 2 years postoperatively. All patients who underwent first-time hip arthroscopy for FAI with a 2-year follow-up were included in this study. Patient-reported outcomes included the mHHS, HOSADL, and visual analogue scale for pain (Pain VAS). Radiological parameters such as alpha angletraditional (αT), alpha anglecartilage (αC), resection arc ratio (% alpha anglecartilage-alpha angletraditional/360°), resection depth (''D''mm) and resection depth ratio 'D%' (D/femoral head diameter %) were measured using the 45° Dunn view. We identified 26 patients (27 hips) with 2-year follow-up. There were 10 female and 16 male patients. The mean age of the patients was 33 ± 12 years.Higher frequency of achieving SCB threshold for mHHS was related to labrum repair (73% vs. debridement '27%' p = 0.03), lower preoperative αT (64° vs. 76°, p = 0.04), lower preoperative mHHS (54 vs. 81, p < 0.001) and higher preoperative VAS scores (8 vs. 7, p = 0.02). Higher frequency of reaching PASS threshold for mHHS was associated with lower αC (82°vs. 92° p:0.02), lower RA (8% vs. 11%, p = 0.03), lower D (2.8 mm vs. 4.5 mm p:0.03), lower D% (4.7% vs. 8.4% p = 0.04) and higher postoperative mHHS (97 vs. 82 p < 0.001). A higher frequency of achieving SCB for HOSADL was related to lower D% (5% vs. 10.5%, p = 0.04).Cam resection depth affects the frequency of achieving clinically meaningful scores and resection depth less than 6% of the femoral head diameter seems to be appropriate for optimal results. The starting point of resection on head cartilage needs to be <90° when alpha angle is used for reference.

A Smartphone App Shows Patients Return to Preoperative Gait Metrics 6 Weeks After Hip Arthroscopy, and Gait Metrics Have Low to Moderate Correlations With a Hip-Specific Patient-Reported Outcome Measure

The purpose of this study was to use a smartphone app to collect gait metrics in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS) and determine when gait metrics return to preoperative levels and if gait metrics correlate with postoperative hip-specific patient-reported outcomes. Patients undergoing primary hip arthroscopy for FAIS from August 2021 to December 2022 were prospectively enrolled. Patients downloaded the iPhone app, rHip, at ∼6 months postoperatively, enabling retroactive access to Apple Health data. Gait metrics included step count, step length, and walking speed. Each patient's preoperative baseline was compared to that individual's successive postoperative week metrics. All patients underwent a standard 4-stage rehabilitation protocol. We compared metrics from beginning to end of each phase (i.e., week 1 to 6 for phase 1) and evaluated correlations with patient outcomes. Fifty patients (40 women; age: 31.9 ± 14.5 years) were included. Patients had significantly reduced step count from postoperative weeks 1 to 5 and improved upon baseline at weeks 13 and 16 to 26. Patients had significantly reduced step length from postoperative weeks 1 to 4 and improved upon baseline at weeks 16 and 20. Patients had significantly lower walking speed from postoperative weeks 1 to 6 and improved upon baseline at week 20 (P < .05). Step count significantly improved over phase 1 rehabilitation (P < .05). Step length and walking speed significantly improved over each of phases 1 to 3 (P < .05 for all). Preoperatively, weak correlations were noted between step length and Patient-Reported Outcomes Measurement Information System (PROMIS) for Physical Function (PF)/Pain, as well as walking speed and Hip Outcome Score-Activities of Daily Living (HOS-ADL)/PROMIS-Pain. At 3 months, moderate correlations were noted between step count and HOS-ADL/12-item international Hip Outcome Tool (iHOT-12), step length and HOS-ADL/PROMIS-PF, and walking speed and HOS-ADL/iHOT-12/PROMIS-PF/PROMIS-Pain. At 6 months, weak to moderate correlations were noted between all 3 gait metrics and HOS-ADL. A smartphone app was capable of capturing health data gait metrics. Patients undergoing hip arthroscopy for FAIS returned to baseline levels in step count, step length, and walking speed after phase 1 (6 weeks) of rehabilitation. The most consistent correlations between gait metrics and step count were seen at 3 months, although only weakto moderate. Gait metrics similarly had weak to moderate correlations with HOS-ADL at 6 months. Level IV, case series.

Medicaid Insurance Is Associated With More Complications and Emergency Department Visits but Equivalent 5-Year Secondary Surgery Rate After Primary Hip Arthroscopy

To compare 90-day complications, 30-day emergency department (ED) visits, and 5-year rate of secondary surgeries for patients with Medicaid vs commercial insurance undergoing primary hip arthroscopy for femoroacetabular impingement syndrome (FAIS) and/or labral tears using a large national database. The PearlDiver Mariner151 database was used to identify patients with International Classification of Diseases, Tenth Revision diagnosis codes for FAIS and/or labral tear who underwent primary hip arthroscopy with femoroplasty, acetabuloplasty, and/or labral repair between 2015 and 2021. Patients with Medicaid were matched 1:4 to a control group of commercially insured patients based on age, sex, body mass index, and Elixhauser Comorbidity Index. Rates of 90-day complications and 30-day ED visits were compared using multivariate regression models. Five-year rates of secondary surgeries-revision arthroscopy or total hip arthroplasty-were compared between cohorts by Kaplan-Meier analysis. A total of 2,033 Medicaid patients were matched with 8,056 commercially insured patients. Rates of adverse events were low; however, Medicaid patients were significantly more likely than commercially insured patients to experience any 90-day complication (2.12% vs 1.43%; odds ratio [OR], 1.2; P= .02). Medicaid patients also experienced more 30-day ED visits than commercially insured patients (8.61% vs 4.28%), and on multivariate logistic regression, insurance status was the strongest determinant of 30-day ED visits (relative to commercial, Medicaid OR, 2.02; P < .001). Despite these differences, 5-year rates of secondary surgeries were comparable between groups (6.1% vs 6.0%; P= .6). In this large national database study, Medicaid patients undergoing primary hip arthroscopy showed significantly greater odds of experiencing 90-day postoperative complications and 30-day ED visits compared to commercially insured patients. Nevertheless, both groups had similar survivorship rates at 5-year follow-up, similar to prior estimates irrespective of insurance. These results document encouraging secondary surgery rates in Medicaid patients.

Global Acetabular Retroversion Is Not Associated With Differences in Outcomes After Primary Hip Arthroscopy Among Patients With Femoroacetabular Impingement Syndrome: A Matched Cohort Study With Minimum 5-Year Follow-Up

To compare hip survivorship and patient-reported outcome measures (PROMs) after primary hip arthroscopy at 5-year follow-up between patients with femoroacetabular impingement syndrome (FAIS) with radiographic signs of global acetabular retroversion and those without. A retrospective matched-cohort study was conducted using a single-surgeon hip arthroscopy database. Patients were included if they underwent primary hip arthroscopy for treatment of FAIS, had preoperative hip x-rays, and had a minimum 5-year follow-up. Global retroversion was defined as the presence of ischial spine sign, posterior wall sign, and crossover sign on anteroposterior view. Patients with FAIS with global retroversion were matched 1:1 on age, sex, and body mass index to FAIS controls. The modified Harris Hip Score (mHHS) and Non-Arthritic Hip Score (NAHS) were administered preoperatively and at follow-up. Hip survivorship and PROMs were compared between the 2 groups using the paired t test, Wilcoxon signed rank test, and/or Cochran-Mantel-Haenszel test as appropriate. P values <.05 were considered significant. Thirty-eight patients with global retroversion (mean age 40.6 ± 10.8 years, 60.5% female) were matched to 38 controls (mean age 41.3 ± 13.6 years, 60.5% female). Reoperation rates were the same in both groups (5.3%). On average, both groups reported significant pre- to postoperative improvement in mHHS (P < .001) and NAHS (P < .001), and there was no significant intergroup differences in the change in mHHS (P= .86) or NAHS (P= .90). Achievement rates for the patient acceptable symptom state on the mHHS were higher among males compared to females (P= .04) in both the global retroversion group (93.3% vs 73.9%) and the control group (93.3% vs 73.9%). Patients with FAIS with and without global acetabular retroversion had no significant difference in outcomes after primary hip arthroscopy at a minimum 5-year minimum follow-up. Level III, retrospective comparative prognostic trial.

Patients Undergoing Revision Hip Arthroscopy Demonstrate Comparable Survivability and Improvement but Worse Postoperative Outcomes Compared to Patients Undergoing Primary Hip Arthroscopy: A Propensity Matched Study at Five-Year Follow-Up

To compare mid-term clinical outcomes between patients undergoing primary hip arthroscopy (HA) versus revision hip arthroscopy (RHA) for femoroacetabular impingement syndrome (FAIS). A retrospective cohort study was conducted on 1,862 patients who underwent hip arthroscopy for FAIS from January 2012 to April 2017. Patients who underwent RHA were propensity matched in a 1:4 ratio by age, sex, body mass index (BMI), and exercise status to patients who underwent primary HA. Preoperative and postoperative radiographs were assessed. Patient-reported outcomes before and at 5 years after surgery, including the Hip Outcome Score Activities of Daily Living subscale (HOS-ADL) and Sports subscale (HOS-SS), modified Harris Hip Score (mHHS), international Hip Outcome Tool (iHOT-12), and Visual Analog Scale (VAS) for Pain and Satisfaction, were compared between groups. Minimally clinically important difference and patient-acceptable symptomatic state (PASS) achievement rates were compared using previously published thresholds. Fifty-one patients who underwent RHA (35 female, 16 male; age 36.2 ± 10.2 years; BMI 26.5 ± 5.9) were followed up for 63.9 ± 9.2 months and then propensity matched in a 1:4 ratio by sex, age, and BMI to 204 control patients who underwent primary HA. At midterm follow-up, patients in the RHA cohort had significantly lower scores for HOS-SS (RHA 64.9 ± 32.5 vs HA 75.3 ± 26.2, P= .044), mHHS (RHA 72.2 ± 22.4 vs HA 80.1 ± 18.1, P= .039), and iHOT-12 (RHA 61.4 ± 29.3 vs HA 71 ± 27.6, P= .043) compared to primary HA patients. Rates of achieving PASS were significantly decreased for HOS-SS (RHA 38.3% vs HA 55.4%, P= .039) and iHOT-12 (RHA 41.9% vs HA 59.9%, P= .035) in the RHA cohort. There were no significant differences in rates of conversion to THA or subsequent reoperation on the index hip between groups. Patients undergoing revision hip arthroscopy demonstrate comparable survivability and magnitude of improvement but may experience worse overall outcome scores and meet thresholds for clinically significant outcomes less often when compared to primary hip arthroscopy patients. Level III; retrospective comparative study.

Reprint of: Class I Obesity Delays Achievement of Patient-Acceptable Symptom State but Not Minimum Clinically Important Difference or Substantial Clinical Benefit After Primary Hip Arthroscopy for Femoroacetabular Impingement Syndrome

To identify differences in the time taken to achieve the minimum clinically important difference (MCID), substantial clinical benefit (SCB), and patient-acceptable symptom state (PASS) following primary hip arthroscopy for the treatment of femoroacetabular impingement syndrome (FAIS) among patients of different body mass index (BMI) categories. We conducted a retrospective comparative study of hip arthroscopy patients with minimum 2-year follow-up. BMI categories were defined as normal (18.5 ≤ BMI < 25.0), overweight (25.0 ≤ BMI <30.0), or class I obese (30.0≤BMI<35.0). All subjects completed the modified Harris Hip Score (mHHS) prior to surgery and at 6 months, 1 year, and 2 years postoperative. MCID and SCB cutoffs were defined as pre-to-postoperative increases in mHHS by ≥8.2 and ≥19.8, respectively. PASS cutoff was set at postoperative mHHS ≥74. Time to achievement of each milestone was compared using the interval-censored EMICM algorithm. The effect of BMI was adjusted for age and sex using an interval-censored proportional hazards model. 285 patients were included in the analysis: 150 (52.6%) normal BMI, 99 (34.7%) overweight, and 36 (12.6%) obese. Obese patients had lower mHHS at baseline (P= .006) and at 2-year follow-up (P= .008). There were no significant intergroup differences in time to achievement for MCID (P= .92) or SCB (P= .69), but obese patients had longer time to PASS than normal BMI patients (P= .047). Multivariable analysis found obesity to be predictive of longer time to PASS (HR= .55; P= .007) but not MCID (HR= 0.91; P= .68) or SCB (HR= 1.06; P= .30). Class I obesity is associated with delays in achieving a literature-defined PASS threshold after primary hip arthroscopy for FAIS. Level III, retrospective comparative study.

Dancers Show Significant Improvement in Outcomes and Favorable Return-to-Dance Rates After Primary Hip Arthroscopy With Femoral Head Cartilage Status Being a Predictor of Secondary Surgical Procedures at Mid-Term Follow-Up

To report minimum 5-year follow-up patient-reported outcome measurement scores (PROMS) and return to dance in dancers who underwent primary hip arthroscopy and to identify predictors for secondary surgeries. Prospectively collected data from May 2010 and June 2016 were retrospectively reviewed. Patients were included if they participated in dance one year prior to surgery at any level, had preoperative and minimum 5-year follow-up scores for the modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), Hip Outcome Score-Sports Specific Subscale (HOS-SSS), and Visual Analog Scale for pain (VAS). Exclusion criteria were previous hip conditions, previous ipsilateral hip surgery, Tönnis grade > 1, or lateral center-edge angle < 18°. The minimal clinically important difference (MCID) was reported. Dancers that discontinued dance for reasons other than pain in their operated hip were excluded from the return to dance analysis. A logistic regression model was used to identify predictors of secondary surgeries. Fifty-one hips (48 female dancers) were included. The average age and follow-up were 29.8 ± 17.2 years and 79.1 ± 23.2 months, respectively. Improvement in all PROMS (P < 0.001) was reported. Achievement rates of MCID for the mHHS, NAHS and VAS were 83.3%, 85.7% and 85.7%, respectively. Five dancers (9.8%) underwent revision hip arthroscopy and four dancers (7.8%) converted to total hip arthroplasty. The rate to return to dance was 78.6%, with 57.6% returning to the pre-injury or higher performance level. Higher femoral head Outerbridge grade was identified as a predictor for secondary surgeries [P = 0.045, odds ratio 6.752, 95% CI (1.043 - 43.688)]. Dancers following primary hip arthroscopy experienced significant improvement in all PROMS collected and achieved a high rate of the MCID at a minimum 5-year follow-up. The rate to return to dance, in dancers that did not discontinue due to lifestyle transition, was 78.6% with 57.6% returning to the pre-injury or higher performance level. Higher femoral head Outerbridge grade was found to be a predictor for secondary surgeries.

Poster 117: Dancers Following Primary Hip Arthroscopy Demonstrate Favorable Outcomes and High Rate of Return to Dance at a Minimum 5-Year Follow-Up

Objectives: The purpose is to report minimum 5-year follow-up patient-reported outcome measurement scores (PROMS) and return to dance in dancers who underwent primary hip arthroscopy, and to identify predictors for secondary surgeries Methods: Prospectively collected data from May 2010 and June 2016 was retrospectively reviewed. Patients were included if they participated in dance one year prior to surgery at any level, had preoperative and minimum 5-year follow-up scores for the modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), Hip Outcome Score–Sports Specific Subscale (HOS-SSS), and Visual Analog Scale for pain (VAS). Exclusion criteria were previous hip conditions, previous ipsilateral hip surgery, Tönnis grade &gt; 1, or lateral center-edge angle &lt; 18°. The minimal clinically important difference (MCID), patient acceptable symptomatic state (PASS), and the maximum outcome improvement (MOI) were reported. A logistic regression model was used to identify predictors of secondary surgeries. Results: Fifty-one hips (48 female dancers) were included. The average age and follow-up were 29.8 ± 17.2 years and 79.1 ± 23.2 months, respectively. Improvement in all PROMS (P &lt; 0.001) was reported. Achievement rates of MCID for the mHHS, NAHS and VAS were 83.3%, 85.7% and 85.7%, respectively. Achievement rates of PASS for the mHHS and the International Hip Outcome Tool–12 were 90.5% and 81%, respectively. The MOI was 73.8% for the mHHS, and 78.6% for the NAHS. Six dancers (14.3%) underwent revision hip arthroscopy and three dancers (5.8%) converted to total hip arthroplasty. The rate to return to dance was 79.1%. Femoral head Outerbridge grade was identified as a predictor for secondary surgeries [P = 0.045, odds ratio 6.752, 95% CI [1.043 – 43.688]). Conclusions: Dancers following primary hip arthroscopy experienced significant improvement in all PROMS and achieved high rates of the MCID, PASS, and MOI at a minimum 5-year follow-up. Further, 89.3% continued to dance with 68% returning to the pre-injury or higher performance level. Femoral head Outerbridge grade was found to be a predictor for secondary surgeries.

Poster 115: Patients who Underwent Primary Hip Arthroscopy for Femoroacetabular Impingement with Acetabular Microfracture Show 77% Survivorship at 10-Year Follow-Up

Objectives: The purpose is to report minimum 10-year follow-up survivorship, defined as non- conversion to total hip arthroplasty (THA), and patient-reported outcome scores (PROS) following primary hip arthroscopy with acetabular microfracture in the setting of femoroacetabular impingement syndrome (FAIS) and acetabular chondral lesions, respectively. Methods: Data was prospectively collected and retrospectively analyzed on all patients who underwent a primary hip arthroscopy and received an acetabular microfracture between June 2009 and January 2011 and included in this study. Patients with a minimum 10-year follow-up for the modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), and the visual analog scale (VAS) for pain were included. If available, the minimum 10-year follow-up for the Hip Outcome Score-Sport-Specific Subscale (HOS-SSS) was reported. The demographics, intraoperative findings, surgical procedures, PROS, rate of achieving the minimal clinical important difference (MCID), and secondary surgeries were analyzed and reported. Results: Twenty-two hips (20 patients) were included in the study, and the mean follow-up time was 124.5 ± 2.2 months. There were 17 hips (77.3%) from males and 5 hips (22.7%) from females. The average patient age at the time of surgery was 42.3 years ± 9.6. All patients on average experienced statistically significant improvement (P &lt; 0.05) between preoperative and minimum 10-year follow-up scores for all PROs. In total, 77.3% of the patients did not require conversion to THA. Additionally, 83.3% of the patients achieved the MCID for the mHHS, NAHS, and VAS for pain. Conclusions: At a minimum 10-year follow-up, survivorship of 77.3% was reported for patients that underwent primary hip arthroscopy with acetabular microfracture for the treatment of FAIS and focal/full-thickness acetabular cartilage lesions. Further, in the patients that did not require THA conversion, significant improvement in all PROS was demonstrated.

Poster 213: Outcomes of High-Level Competitive Athletes Undergoing Hip Arthroscopy as Compared to Non-Competitive Athletes at 5-Year Follow-Up: A Propensity Matched Analysis

Objectives: Hip arthroscopy has been proven to be an effective treatment for femoroacetabular impingement syndrome (FAIS) in both competitive athletes and non-competitive athletes, with favorable patient reported outcomes (PROs), and low rates of complications. Previous data demonstrates a high return to sport (RTS) rate, reported up to 88% to 92%. Although PROs and RTS have previously been evaluated, many studies are limited to short-term follow-up and do not differentiate between competitive and non-competitive athletes. The objectives of this study were to (1) determine differences in mid-term clinical outcomes at 5-years follow-up between patients who are high-level competitive athletes (CA) versus propensity matched, non-competitive athletes (NCA) undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS), (2) determine whether achievement rates of minimal clinically important differences (MCID) and patient acceptable symptomatic states (PASS) differ between the two groups, and (3) determine return to sport (RTS) rate in CA. Methods: Patients who were collegiate, semi-professional, or professional athletes and underwent primary hip arthroscopy for FAIS from January 2012 to April 2017 were identified. Patients were propensity matched on a 1:4 basis to NCA controls by age, sex, and body mass index (BMI). Preoperative and postoperative radiographs were assessed. Patient reported outcomes (PROs) collected preoperatively and at 5-years included international Hip Outcome Tool (iHOT-12), modified Harris Hip Score (mHHS), Hip Outcome Score Activities of Daily Living subscale (HOS-ADL) and Sports subscale (HOS-SS), and Visual Analog Scale (VAS) for Pain and Satisfaction. MCID and PASS rates were determined using previously-published thresholds for iHOT-12, mHHS, HOS-ADL, HOS-SS, and VAS Pain. RTS rate and duration was collected retrospectively. Results: A total of 57 high-level CA who underwent primary hip arthroscopy for FAIS (33 female, age: 21.7 ± 4.2 years, BMI: 23.1 ± 2.8kg/m2) were propensity matched to 228 NCA controls (132 female, p &gt; 0.999; age: 23.3 ± 5.8 years, p = 0.022; BMI: 23.8 ± 4.3 kg/m2, p = 0.239). There were no statistically significant differences between any radiographic parameters in any of the pre- or postoperative radiographic parameters between groups. Of note, competitive athletes had higher outcome scores prior to surgery in HOS-ADL (CA: 74.9 ± 13.7 vs NCA: 66.4 ± 18.4, p = 0.001) and mHHS (CA: 64.7 ± 12.9 vs NCA: 59.7 ± 14.3, p = 0.040). Both groups demonstrated significant postoperative improvements in all outcome scores measured (p ≤ 0.001). At 5-years postoperatively, CA had lower VAS pain than NCA (CA: 17.3 ± 17.6 vs NCA: 24.7 ± 25.9, p=0.017). There were no significant differences in achieving MCID or PASS for HOS-ADL, HOS-SS, mHHS, or iHOT-12 at final follow-up. CA returned to sport (RTS) at a median of 25.2 weeks (Q1 22.4 – Q3 30.7) with an overall RTS rate of 90%. The CA participated in a multitude of sports (Figure 1) however, there was no significant differences in comparing RTS between individual sports (p = 0.163) (Figure 2). Conclusions: CA patients demonstrated significant and durable improvements in PROs as well as high MCID and PASS achievement rates following primary hip arthroscopy, which were comparable to non- competitive controls. Clinicians should be aware that CA patients demonstrate higher preoperative mHHS and HOS-ADL scores than controls and achieve lower average self-reported pain at 5-years postoperatively. CA patients demonstrate high rate of RTS (˜90%) at a median of ˜25 weeks post- operatively.

Poster 232: Clinical Outcomes Among Individuals with Global Acetabular Retroversion who Underwent Hip Arthroscopy for FAI with Minimum 5-Year Follow-Up

Objectives: The purpose of this study was to compare functional outcomes and clinical threshold achievement rates of patients with radiographic signs of global acetabular retroversion who underwent hip arthroscopy for FAI with minimum follow-up of 5 years. Methods: Patients were identified from a single-surgeon prospectively-collected database who underwent primary hip arthroscopy for treatment of FAI. Patients completed patient-reported outcome (PRO) surveys at both baseline and at 5-year follow-up. Demographic data was collected including age, sex, BMI at time of surgery, and patient-reported symptom length. Intraoperative findings were recorded, including the Outerbridge grade, presence of labral tears, chondral delamination, subspine impingement, cam lesions, pincer lesions, and mixed-type FAI. Global acetabular retroversion was assessed on AP view using three radiographic signs: ischial spine, posterior wall, and crossover signs. Other radiographic measures included alpha angle measured on three view (AP, 45° Dunn, 90° Dunn), lateral center edge angle (LCEA), and Tönnis grade. Results: We identified 124 primary hip arthroscopy patients who had minimum 5-year follow-up with adequate imaging and complete 5-year PROs. Preoperative X-rays demonstrated presence of ischial spine sign in 65 patients (52.4%), posterior wall sign in 61 patients (49.2%), and crossover sign in 75 patients (60.5%). Mean alpha angle was highest on AP view (62.2°), followed by 45° Dunn view (55.9°) and 90° Dunn view (50.9°) and mean LCEA was 38.5°. A baseline comparison demonstrated no significant differences between groups in age, sex, BMI, preoperative symptom length, Tönnis grade, Outerbridge grade, and preoperative mHHS or NAHS (p&gt;0.05). At 5-year follow-up, patients reported significant improvement in both mHHS (mean 50.4 to 82.7, p&lt;0.001) and NAHS (49.4 to 85.5, p&lt;0.001). Achievement rates were high for MCID (90.3%), SCB (80.7%), and PASS (79.0%) for the mHHS. Three-way frequency comparison of acetabular retroversion signs found that all three signs tended to be present together (40 patients, 32.3%) or absent together (31 patients, 25.0%). Pairwise comparisons with tetrachoric correlation testing found all three signs to be significantly correlated with one another: ischial spine sign versus posterior wall (rtet=0.65, corrected p&lt;0.001), ischial spine sign versus crossover sign (rtet=0.74, corrected p&lt;0.001), and posterior wall sign versus crossover sign (rtet=0.51, corrected p&lt;0.001). Multivariable analysis did not find any of the three signs to be significant independent predictors of 5-year improvement in mHHS or NAHS (p&gt;0.05). Posterior wall sign was associated with lower odds of achieving the MCID (OR = 0.62, 95% CI [0.06 to 1.09]) but this did not achieve significance (χ2=3.39, p=0.07). Overall, achievement rates for MCID, SCB, and PASS did not significantly differ between the cohorts with respect to each sign (p&gt;0.05). Conclusions: Clinical outcomes and achievement rates at 5-year follow-up demonstrated no significant differences among patients with respect to each sign of acetabular retroversion based on mHHS, NAHS, MCID, SCB and PASS. Surgeons should be reassured that these patients regain function at a rate similar to the greater FAI population.

Paper 13: Traction Application Method Influences Force and Distraction Parameters at Venting and Capsulotomy

Objectives: This study examined the effects of traction application method – either a standard peroneal post or a postless method -- on traction and distraction variables before and after venting and capsulotomy. A more robust understanding of the direct effects of each intervention under different traction conditions may inform clinical decisions about compartment access and/or methods of traction application. Methods: Fluoroscopic images were taken before and after traction application, venting, and capsulotomy in primary hip arthroscopies by a single surgeon; these were used to measure distraction distances, which were each normalized to the diameter of the femoral head in the same image to account for the effect any purely positional differences across time points. Traction forces were also recorded at traction application, before/after venting, and before/after capsulotomy. Traction method, as well as sex and hamstring flexibility scores (known to influence degree of distraction) were assessed via standard least squares models for their effects on: 1) Instantaneous traction forces before venting, after venting, before capsulotomy, and after capsulotomy 2) Distraction differences -- expressed as % femoral head diameter -- between the neutral state and the values at these same interventions 3) The ratios of normalized distraction differences to traction forces at each intervention Results: Both initial distraction and after-venting distraction values differed significantly with respect to sex (distraction: p&lt;0.0001, venting: p&lt;0.0001 ), and hamstring flexibility (distraction: p&lt;0.0140, venting: p&lt;0.0040), with larger distraction magnitudes in female and more flexible patients. After-capsulotomy distraction differed with sex (p&lt;0.0001) and traction method (p&lt;0.0056), with female and peroneal post-distracted patients exhibiting higher distraction magnitudes. All force values along the intervention trajectory (before and after venting, before and after capsulotomy) differed with respect to sex and traction method, but not with hamstring flexibility (Table1). Male patients and post-distracted patients exhibited higher forces. Distraction-traction ratios (distraction achieved per unit force applied) differed with respect to sex, traction method, and hamstring flexibility at all interventions – except for the after-capsulotomy ratio, which was unaffected by hamstring flexibility (Table 1). Higher values (more distraction achieved per unit force) were seen in more flexible patients, female patients, and patients distracted via the postless method. The differences between ratios before and after an intervention differed with respect to sex for venting (p&lt;0.0106), and both sex and traction method for capsulotomy (sex: p&lt;0.0001 traction: p&lt;0.0379), representing more distraction achieved per unit force after capsulotomy in the post-distracted group, and for female patients at both interventions. Conclusions: The distraction results indicate that the posted and postless methods of traction application do not differ significantly in the magnitude of distraction achieved (except after capsulotomy), but depend more on patient flexibility. The fact that after-capsulotomy distractions are larger in the post-distracted group may point to differences in soft tissue strain patterns between traction application methods. Traction forces are higher in post-distracted group but yield lower distraction distances per unit force than the postless method overall; the exception to this pattern is the ratio taken after capsulotomy, which is higher in the post-distracted group. Taken together, these results may support a switch to postless methods and invite further investigation into the anatomical and mechanical patterns governing capsular integrity.

Poster 229: Expectations for Return to Sport Before and After Hip Arthroscopy with Minimum 1-year Follow-Up

Objectives: Setting appropriate expectations for orthopedic surgery functional outcomes can contribute to postoperative motivation and satisfaction. For hip arthroscopy, the literature is limited regarding patients’ expectations for returning to sport. This study aims to compare preoperative expectations with postoperative return-to-sport status in patients who underwent primary hip arthroscopy. Methods: We conducted a prospective cohort study of patients who underwent primary hip arthroscopy. Return to sport expectations were recorded preoperatively. Return to preinjury sport status was assessed along with updated sport expectations at a minimum of 1 year follow-up after surgery (range 1.1 to 2.6 years; mean 2.0 years). The proportion of patients who expected to return was compared to actual return rates. Results: Thirty-five patients who underwent hip arthroscopy were prospectively recruited. Preoperatively, 31 patients (88.6%) expected to return to their preinjury sport level, while only 16 (45.7%) actually returned to that level. 34 (97.1%) expected to return to their main sport and 22 (62.9%) actually returned. 9/35 returned to their preinjury primary sport at a lower level. 10/35 patients had completely given up their original sport by time of follow-up. All 11 patients who reported a change in their primary sport chose a lower impact sport, transitioning from tennis, running, kickboxing, frisbee, volleyball to cycling, pilates, walking, and yoga. Logistical regression found no significant difference between expectations and return to sport level when controlling for age, BMI, gender. Conclusions: This study found a significant difference between preinjury return-to-sport expectations and actual return rates following hip surgery. Although patients had high expectations for recovery, a majority did not return to their preinjury sport level and a high portion did not return at all. All patients that took up a different sport went from one of high impact to low impact. These data can provide more realistic return-to-sport expectations for patients undergoing hip arthroscopy.

Poster 212: Return to Sport Rate of Collegiate Athletes Following Primary Hip Arthroscopy for Femoroacetabular Impingement

Objectives: Athletic participation has been increasingly associated with symptomatic femoroacetabular impingement (FAI). High-intensity and repetitive sporting activities, especially those involving “at-risk” hip positions, can increase the risk for developing FAI. Numerous studies have shown that elite athletes can return to play at the professional level after undergoing hip arthroscopy. However, there is minimal data on return to sport rate and outcomes at the collegiate level. The purpose of this study is to determine the return to sport (RTS) rate of collegiate athletes following hip arthroscopy for treatment of FAI. Methods: Patients who were collegiate athletes and underwent hip arthroscopy surgery for treatment of FAI performed by a single surgeon between January 2010 and May 2020 were included. Patients who were in their final year of eligibility, graduated, retired or had plans to retire from collegiate play prior to surgery, or who had undergone prior ipsilateral hip surgery were excluded. Publicly available data was collected on each patient’s collegiate team and division, RTS status after surgery, and level of play after surgery. Successful RTS was defined as competing in a competition at the collegiate level after surgery. If both hips were operated on during the same season, then RTS was the same for both hips. Comparisons between RTS and no RTS groups were performed with the Mann-Whitney U test for continuous endpoints and Fisher’s exact test or Pearson’s Chi-squared test for categorical or binary endpoints. Results: A total of 181 hips (in 148 unique athletes) met inclusion criteria comprised of 114 male (63%) and 67 female (37%) hips with mean age of 20.5±1.5 (Table 1). Thirty-eight patients had bilateral hip arthroscopy. Patients were collegiate athletes in 19 different sports with football (17% of hips), soccer (15%), ice hockey (14%), and baseball (8%) the most commonly played (Table 2). The majority of patients played at the Division I level (n=140 hips, 79%). There were 19 patients with borderline dysplasia (lateral center-edge angle (LCEA)=20-25 degrees) and 7 patients with dysplastic hips (LCEA &lt;20 degress). Severe cartilage defects (Outbridge III/IV) were found in 41 hips (23%) with 15 hips (8%) undergoing microfracture. Eighty-six percent (155 hips) returned to sport at the collegiate level following hip arthroscopy. Males were significantly less likely to RTS compared to females (82% vs 93%, OR = 2.8, 95% CI [1.003, 7.819], p=0.042). Patients who RTS did have a marginally statistically significantly higher mean pre-operative SF-12 MCS compared to those who did not (55±9 vs 51±9, p=0.050). There was no signficiant association between the RTS and no RTS groups with respect to preoperative alpha angle, minimum joint space, LCEA or dysplasia category, collegiate division, presence or treatment of severe cartilage defect, or pre-operative outcome scores relating primarily to pain or physical function (mHHS, HOS-ADL, HOS-Sport, SF-12 PCS) (p&gt;0.05 for all). Conclusions: There is a high return to sport rate among collegiate athletes following hip arthroscopy for the treatment of FAI. Male athletes and those with lower preoperative SF-12 MCS scores may be at risk for lower likelihood of return to collegiate competition. [Table: see text][Table: see text]

Poster 142: Capsular Repair Demonstrates Similar Restoration of Resistance to Axial Distraction in Interportal and Periportal Capsulotomies: An In Vivo Propensity Matched Cohort Study

Objectives: Hip arthroscopy has become increasingly prevalent in the United States for treating young adult hip disorders. The periportal capsulotomy, in comparison to the interportal capsulotomy, has been proposed as a technique for decreasing post-arthroscopy hip instability; however, the effects of this technique are largely theoretical. The objectives of this study were to compare the intraoperative distraction profiles of hip arthroscopy patients undergoing interportal versus periportal capsulotomies. The authors hypothesized the periportal capsulotomy would demonstrate greater resistance to axial distraction at both 1) the capsulotomy and 2) final capsular repair, when compared to the interportal capsulotomy. Methods: Patients undergoing primary hip arthroscopy by a single surgeon underwent intraoperative axial distraction testing at 25-, 50-, 75-, and 100-pounds force with each axial distraction distance measured by standardized, normalized fluoroscopic evaluation. Demographics, hip radiographic characteristics, and distraction distance measurements were collected on patients undergoing periportal capsulotomy and on a historical control group undergoing an interportal capsulotomy (Figure 1). Propensity matching was conducted using native state distraction, lateral center edge angle, and gender as covariate to achieve balance between groups. Between group comparisons were then conducted across the matched interportal and periportal groups. Student’s T-test for continuous variables and the Fisher exact test for categorical variables. Intragroup comparison was conducted across three capsule states: native, capsulotomy, and repair. Sequential testing of capsular states for each patient was conducted with the paired T-test. Results: Seventy-four interportal capsulotomies and 122 periportal capsulotomies were identified. Propensity matching yielded 74 hips in each group with standard mean differences of &lt;0.03. Demographic and radiographic characteristics were similar between matched cohorts (p &gt; 0.05) (Table 1). Distraction distances were similar between the interportal and periportal groups in both the capsulotomy and repair states (p &gt; 0.05), while the periportal capsulotomy repair demonstrated decreased hip distraction distance when compared to the native state by 1.48mm at 75lbf and 1.54mm at 100lbf (p &lt; 0.001) (Figure 2). Conclusions: The present study demonstrates that periportal capsulotomy and interportal capsulotomy have similar effects on in vivo hip distractibility. An unrepaired interportal capsulotomy led to an increase in hip distraction of 2.71 mm at 100 lbf (p &lt; 0.001) compared to the native state, while an unrepaired periportal capsulotomy led to an increase in hip distraction of 2.44 mm at 100 lbf (p &lt; 0.001). The periportal capsulotomy technique has been discussed as having the unique advantage of not fully disrupting the iliofemoral ligament and therefore potentially not require a repair; however, the results of the present study indicate that it is biomechanically similar to the interportal capsulotomy in the unrepaired state. Although this finding does not definitively establish a need for capsular repair in all cases when utilizing a periportal capsulotomy, if the surgeon wishes to re-establish native biomechanics, repair should be considered. The present study establishes the in vivo, intraoperative biomechanics of the periportal capsulotomy, for which there were previously no available data. Further, this study establishes that although periportal capsulotomy is a minimally disruptive technique, it has a substantial effect on in-vivo, intraoperative hip stability as measured by hip distraction distance as a result of axial traction forces. While this paper is able to address the biomechanics at the time of surgery, this paper cannot make any conclusions about the healing potential of the capsule when comparing an interportal and a periportal capsulotomy. In conclusion, an unrepaired periportal capsulotomy and interportal capsulotomy have a similar effect on increasing hip axial distraction distance intra-operatively. Performing a capsular repair restores intra- operative resistance to axial distraction in both the periportal and interportal capsulotomy. [Table: see text]

Paper 63: Return to Long Distance Running After Hip Arthroscopy for Femoroacetabular Impingement

Objectives: Arthroscopic hip surgery for femoroacetabular impingement (FAI) has shown high rates of return to different sports in athletes. No studies to date have focused on patients’ return to long- distance running, a running sport with unique characteristics and demands. The purpose of this study was to determine return to long-distance running rates and changes in running performance in long distance runners undergoing hip arthroscopic surgery for the treatment of FAI and to identify possible risk factors associated with not returning to long distance running. Methods: An institutional hip preservation registry was retrospectively reviewed for patients identified as long distance runners (half marathons and marathons) who underwent primary hip arthroscopies for FAI performed between March 2010 and January 2017. Patient demographics and injury characteristics as well as clinical and radiographic findings were recorded. All patients were contacted for return to running information using a running specific return to sport questionnaire. Multivariable logistic regression analysis was used to identify potential risk factors for not returning to long-distance running. Results: Sixty-eight long distance runners (78 hips) were included. Mean patient age and body mass index (BMI) were 37.8±8.9 years and 23.8±3.3 kg/m2, respectively. Thirty-eight (56%) were female runners. Mean weekly running milage prior to injury was 34.5±16.9 miles. Mean duration of hip symptoms prior to seeking medical evaluation was 77.3±16.9 weeks. Fifty-nine runners (87%) had to stop or modify their running for a mean duration of 44.3±45 weeks prior to surgery due to hip symptoms. Overall, 50 runners (74%) returned to any running, of which 25 runners (50%) returned to long distance running completing half/full marathons races after surgery. Most common reasons for not returning to running were pain or discomfort (50%) followed by fear of re-injury (22%) and additional different injuries (22%). Among runners who did not return to any running, 12 (67%) reported satisfaction from surgery. Multivariable logistic regression analysis revealed female runners (odds ratio [OR]=0.2; confidence interval [CI]=0.0 to 0.9; p=0.034) and hips with radiologic findings of higher alpha angles (OR=0.9; 95% CI=0.9 to 1.0; p=0.045) were less likely to return to long distance running. Conclusions: Hip arthroscopic treatment for FAI in symptomatic long-distance runners, a distinctive subgroup of runners, allowed most of them (74%) to return to running, however only 40% returned to long distance running races. Female runners and runners with radiologic findings of higher alpha angles were less likely to return to long-distance running. These data can better guide clinicians and long- distance runners with realistic expectations related to the arthroscopic management of symptomatic FAI.

Five-Year Outcomes of Primary Hip Arthroscopy for Femoroacetabular Impingement Syndrome Among Female Patients: Higher Body Mass Index Is Associated With Reduced Clinically Significant Outcomes

To evaluate the impact of age, body mass index (BMI), and symptom duration on 5-year clinical outcomes among females following primary hip arthroscopy for femoroacetabular impingement syndrome (FAIS). We conducted a retrospective review of a prospectively collected database of hip arthroscopy patients with a minimum 5-year follow-up. Patients were stratified by age (<30, 30-45, ≥45 years), BMI (<25.0, 25.0-29.9, ≥30.0), and preoperative symptom duration (<1 vs ≥1 year). Patient-reported outcomes were assessed using the modified Harris Hip Score (mHHS) and Non-Arthritic Hip Score (NAHS). Pre- to postoperative improvement in mHHS and NAHS was compared between groups using the Mann-Whitney U test or Kruskal-Wallis test. Hip survivorship rates and minimum clinically important difference (MCID) achievement rates were compared with Fisher exact test. Predictors of outcomes were identified using multivariable linear and logistic regression. P values <.05 were considered significant. In total, 103 patients were included in the analysis with a mean age of 42.0 ± 12.6 years (range, 16-75) and mean BMI of 24.9 ± 4.8 (range, 17.2-38.9). Most patients had symptoms of duration ≥1 year (60.2%). Six patients (5.8%) had arthroscopic revisions, and 2 patients (1.9%) converted to total hip arthroplasty by 5-year follow-up. Patients with BMI ≥30.0 had significantly lower postoperative mHHS (P= .03) and NAHS (P= .04) than those with BMI <25.0. Higher BMI was associated with reduced improvement in mHHS (β= -1.14, P= .02) and NAHS (β= -1.34, P < .001) and lower odds of achieving the mHHS MCID (odds ratio [OR]= 0.82, P= .02) and NAHS MCID (OR= 0.88, P= .04). Older age was predictive of reduced improvement in NAHS (β= -0.31, P= .046). Symptom duration ≥1 year was predictive of higher odds of achieving the NAHS MCID (OR= 3.98, P= .02). Female patients across a wide range of ages, BMIs, and symptom durations experience satisfactory 5-year outcomes following primary hip arthroscopy, but higher BMI is associated with reduced improvement in patient-reported outcomes. Level III, retrospective comparative prognostic trial.